CONFIDENTIAL

107 - A
D IPR Questionnaire No. 107- A (Revised)
O.I.R.

PERSONAL INFORMATION QUESTIONNAIRE

Batch No.

Selection Board (No. & Place)

Chest No.

Name in CAPITALS (As in the matriculation certificate)

UPSC / Other Roll No.

__________________________________________________________________

Fathers Name

__________________________________________________________________

(a)
Place of Maximum Residence (Place, District, State)
(with approximate population of the place)

__________________________________________________________________

Place of Present Residence (Place, District, State)

(with approximate population of the place)

__________________________________________________________________

Place of Permanent Residence (Place, District, State)

(with approximate population of the place)

__________________________________________________________________

(b)

(c)

(Whether District HQ or not)

__________________________________________________________________

Fill in the details below :-

State & District

Religion

(a)

Whether SC

Mother Tongue

ST OBC

Parents Alive

Date of Birth

Married Single Widower

Yes / No

(b)
If not alive, your age at the time of Mother s / Fathers death
(c)

__________________________________________________________________
Parents / Guardians and Siblings Occupatio n/ income (as applicable) :-

Particulars

Education

Occupation

Income per month

Father
Mother
Guardian
Elder Brother

Sister

Elder Brother

Sister

Younger Brother

Sister

Younger Brother

Sister
Educational Record (commencing from Matriculatio n / Equivalent Examination) :-

Qualification
acquired

Full Name of
Institution

Board
University

Year

Div.
& Marks %

Matric Hr. Sec.

10+2
10+2 Equivalent
Graduation

Post-Graduation
Professional

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Medium of
Instruction

Boarder Day
Scholar

Outstanding
achievement, if any

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/ Age ( Years & Months)

/ Height (in Metre)

/ Weight (in Kilogram)

______________________________________

_____________________________

__________________________________

Present Occupation and personal monthly income, if any

______________________________________________________________________________

(a)

N.C.C. Training

(b)

Yes / No

If Yes, Total Training (Give details below)

Wing

Total Training

(a)

Division

Certificate Obtained

Participation in games & sports :Period or duration

(b)

Represented
School / College / University / Other

of Participation

Games Sports

Hobbies / Interest

Outstanding achievement, if any

______________________________________________________________________________

(c)

Participation in extra-curricular, activities :Duration of Participation

Name of the activity group

Outstanding achievement, if any

(d)
Position of responsiblity/offices held in NCC/Scouting
Sports Team/Extra-curricular group and other fields
(a)
(b)

______________________________________________________________________________
______________________________________________________________________________

Nature of Commission
Choice of Service

Number of chances availed for commission in all three Services ______________________________________________________________________________

Details of all previous interviews, if any (Army

Navy Air Force Selection Boards)

Date

Sl. No.

Type of Entry

SSB No. & Place

Chest No.

CONFIDENTIAL

Batch No.